What is the recommended treatment regimen for hospitalized patients with asthma exacerbation using intravenous (IV) corticosteroids?

IV Corticosteroids for Hospitalized Patients with Asthma Exacerbation

There is no advantage to using intravenous corticosteroids over oral therapy for hospitalized patients with asthma exacerbation, provided gastrointestinal transit time or absorption is not impaired. 1

Primary Treatment Components

• Systemic corticosteroids are a cornerstone of asthma exacerbation treatment and should be administered early as they are the only treatment effective for the inflammatory component of asthma 1
• The anti-inflammatory effects of corticosteroids may not be apparent for 6-12 hours after administration, making early administration critical 1
• Primary treatment for all asthma exacerbations includes:
  • Oxygen (to maintain SaO₂ >90%, or >95% in pregnant women and patients with heart disease) 1
  • Inhaled short-acting β₂-agonists 1
  • Systemic corticosteroids 1

Corticosteroid Administration

Dosing Recommendations

• For adults: 40-80 mg/day of prednisone in 1 or 2 divided doses until peak expiratory flow (PEF) reaches 70% of predicted or personal best 1
• For children: 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until PEF is 70% of predicted or personal best 1
• When high-dose therapy is desired, methylprednisolone sodium succinate can be administered at 30 mg/kg intravenously over at least 30 minutes, repeated every 4-6 hours for 48 hours 2

Route of Administration

• Oral administration of prednisone has effects equivalent to intravenous methylprednisolone but is less invasive 1
• Multiple studies have demonstrated no significant difference in efficacy between oral and intravenous corticosteroids:
  • A randomized controlled study showed similar improvements in peak expiratory flow rate after 72 hours between oral prednisolone and IV hydrocortisone groups 3
  • In children, oral prednisone was as effective as IV methylprednisolone with no difference in length of hospital stay 4
  • Hospital admission rates were similar in children given oral or IV methylprednisolone 5

Duration of Treatment

• The total course of systemic corticosteroids for an asthma exacerbation requiring hospitalization may last from 3 to 10 days 1
• For corticosteroid courses of less than 1 week, there is no need to taper the dose 1
• For slightly longer courses (up to 10 days), there probably is no need to taper, especially if patients are concurrently taking inhaled corticosteroids 1
• High-dose corticosteroid therapy should generally be continued only until the patient's condition has stabilized, usually not beyond 48 to 72 hours 2

Special Considerations

• Intravenous administration should be considered when:
  • Patients are unable to take oral medications due to vomiting, respiratory distress, or altered mental status 1
  • Gastrointestinal transit time or absorption is impaired 1
• Rapid IV administration of large doses of methylprednisolone (>0.5 gram over <10 minutes) has been associated with cardiac arrhythmias and/or cardiac arrest 2
• Bradycardia has been reported during or after administration of large doses of methylprednisolone 2

Adjunctive Treatments

• Inhaled ipratropium bromide should be added to β₂-agonist therapy in severe exacerbations to increase bronchodilation 1
• IV magnesium sulfate (2g over 20 minutes in adults) can moderately improve pulmonary function in patients with severe refractory asthma 1

Treatment at Discharge

• Patients should receive oral prednisone (30 mg daily or more) for 1-3 weeks 6
• Inhaled corticosteroids should be prescribed at higher doses than before admission 6
• A written asthma action plan and peak flow meter should be provided 6
• Follow-up with primary care within 1 week and respiratory specialist within 4 weeks is recommended 6